Assessments and point of care charting, comment

Assessments and point of care charting Assessing the patients and directly inputting the information electronically can help with many things. Obtaining correct information, location, description, improving and worsening data can improve if we are able to input all the information at the patients bedside. I agree with the other writer about the COWS. I have never used one in a patients room. Working in Emergency, we often write things down on a piece of paper and use our memory for what is not jotted down. The only time it is fitting for us in Emergency to use a COW is during a Code where inputting the medications and procedures as they are being done saves a lot of time. If you simply write down each step on a piece of paper, then sit down to chart on the computer after it can take up to 20-30 minutes. Another idea instead of COWS or small hand held devices is to give each nurse her own laptop to use for the day and give it to the next shift as they come in. Lap tops are not too small or too big. Charting at the bedside for assessments and having the MAR on hand to check at bedside is helpful.

Original PostMarch 1, 2010Title: Assessments and point of care chartingI absolutely agree with all the comments presented in the below link. Being that computerized documentation is less than 6 months old in our main facility, bedside point of care charting is a relatively new concept. It used to be that the only documentation performed at the bedside was the patient database and even then, most of that information was gathered on initial assessment and we would then go out to the desk to complete the paperwork. I think as more organizations embrace technology, more thought needs to go into the purchasing of equipment. At our facility, the managers for each unit were given a budget to purchase the style of computer they thought would be best suited for that particular unit. Pods were designed with central computers, handheld devices were purchased as well as COWs (computer on wheels). Many units after the fact discovered that the COWS were too big to get to the second bed in the room. This caused non-compliance with The Joint Commission standard stating that the e-mar must be at the bedside when administering medications. Other units found the hand held devices to small to use – the type to difficult to read. Pods are great for the primary nursing concept but takes the nurse away from the bedside. Many areas discovered just how few available outlets they had how short a battery life really is. We even had to become politically correct when a patient complained to administration that she overheard a nurse in the ER referring to "that stupid COW that had died in the hallway" – not realizing the nurse was frustrated that no one had bothered to plug the computer in to charge. We now refer to COWS as WOWS – work stations on wheels. With all that aside, we are finding that wall based point of care computers work best allowing optimal contact with the patient while gathering crucial information to be utilized in their treatment of care – as long as the computer is not on a wall that forces your back to the patient the entire time you are typing!

Original PostDecember 14, 2009Title: Assessments and Point of Care ChartingCharting patient assessments is often a time consuming task, but vital to the care of the patient and record keeping. Nursing often jot notes down on a piece of paper, to only later record them into the computer system. Much may be lost in the translation. In addition, actions may be taken on the charting that in currently in the computer, though it may not always be the most current reflection of the patent’s status. Point of care systems have become paramount for charting in acute care settings, especially on critical care units. They often interface with medical devices to collect data automatically. These systems are often flowsheet orientated and provide graphing and trending capabilities. Optimally these systems create less redundancy, offer quick responses and interface with other clinical operations such as the laboratory and pharmacy departments. The computer availability is also an important consideration. Central computers have not always enhanced charting as they may take nurse from the bedside. Point of care charting should be convenient points of access to the system. Computers on Wheels (COWS) are found in many organizations. The portable, efficient system allows the nurse to chart in the patients room when appropriate. Bedside systems at the point of care focus on quickly capturing information that a nurse may otherwise jot down on their notes. Computer location should be given thoughtful consideration before investments are made in addition to the device’s speed and ease of use.

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